A Driver Substance Abuse

Previous Work History Verification Release

TO BE COMPLETED BY PROSPECTIVE CANDIDATE

This information is being requested in compliance with §40.25(b) and 391.23(a). RELEASE -

I hereby authorize all companies/vendors listed below to release records of employment, including accident history and drug/alcohol testing records, to First Advantage on behalf of First Student.Drug/alcohol testing records include: I, Young Adam Delano

Last, First, Middle Initial

Last four digits of Social Security number 1091

(1) Information as to whether, within the previous three years, the driver had violated the alcohol and controlled substances prohibitions under 49 CFR Part 382 or 49 CFR Part 40

(2) Information as to whether the driver failed to undertake or complete a rehabilitation program prescribed by a substance abuse professional (SAP) pursuant to 49 CFR §382.605 or 49 CFR Part 40, Subpart 0

(3) For a driver who had successfully completed an SAP's rehabilitation referral, and remained in the employ of the referring employer, information on whether the driver had the following testing violations subsequent to completion of a referral: l (i) Alcohol tests with a result of 0.04 or higher alcohol concentration l (ii) Verified positive drug tests

l (iii)Refusals to be tested (including verified adulterated or substituted drug test results) I hereby release all companies/vendors listed below for any and all liability of any type as a result of providing information requested by First Advantage on behalf of First Student.

l Present Employer #1:

l Present Employer #2:

l Present Employer #3:

l Previous Employer #1:

l Previous Employer #2:

l Previous Employer #3:

l Previous Employer #4:

l Previous Employer #5:

l Previous Employer #6:

l Previous Employer #7:

l Previous Employer #8:

l Previous Employer #9:

l Previous Employer #10:

l Previous Employer #11:

l Previous Employer #12:

I Certify Yes

ESignature

Young, Adam (AILKGD2FJY) Release - Page 1 of 2 May 17, 2024 05:39:25 PM GMT Pursuant to 49 C.F.R. section 391.23(i), you have the following rights with respect to the investigative information that First Advantage, acting on behalf of First Student, receives from your previous DOT-regulated employers:

(1) You have the right to review the information provided to First Advantage on behalf of First Student by your previous DOT-regulated employers.

l

(2) You have the right to have errors in the information provided to First Advantage on behalf of First Student by your previous DOT-regulated employers corrected by that previous employer and for that previous employer to re-send the corrected information to First Advantage. l

(3) You have the right to have a rebuttal statement attached to the alleged erroneous information provided by your previous employer if you and your previous employer cannot agree on the accuracy of the information. l

To review the information provided to First Advantage on behalf of First Student by your previous DOT-regulated employers, you must contact First Advantage by phone or in writing:

First Advantage Background Services Corp.

Consumer Center

P.O. Box 105292

Atlanta, GA 30348

Call: 800-***-****

The request may be submitted at any time until as late as 30 days after being qualified or being informed of a denial of qualification by First Student. First Advantage, acting on behalf of First Student, will provide this information to you within five days of receiving your request. If First Advantage has not yet received the information from your previous employer at the time of your request, then First Advantage will make this information available to you within five days after it is received by First Advantage. If you fail to arrange to pick up or receive these records within 30 days after First Advantage makes them available, First Advantage may consider you to have waived your request to review the records. Young, Adam (AILKGD2FJY) Release - Page 2 of 2 May 17, 2024 05:39:25 PM GMT

Contact this candidate